Healthcare Provider Details

I. General information

NPI: 1467299529
Provider Name (Legal Business Name): EL SHADAI A GEBE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2024
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 BIELENBERG DR STE 102-104
WOODBURY MN
55125-1700
US

IV. Provider business mailing address

2545 LIBERTY RDG
WOODBURY MN
55129-6712
US

V. Phone/Fax

Practice location:
  • Phone: 651-528-1257
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: